PRACTICE OPPORTUNITIES FOR C. difficile PREVENTION1,2
For Hospitals and Skilled Nursing Facilities
(revised November 2011)
TOPIC / PRACTICE RECOMMENDATION OPTIONSIdentification of patients with suspect CDI
Patient
assessment / 1. Develop list of risk factors for CDI
2. Assess all patients with signs and symptoms of CDI and risk factors
3. Assess for past history of CDI.
Microbiological testing / 1. Develop guidelines for testing for optimal results and efficiency of response;
how many samples per day, quality of specimens, consistency of stool, how many samples per hospital stay or exacerbation of symptoms
2. Utilize appropriate method of testing for C. difficile
3. Develop mechanism for immediate notification of test results to MD/Unit/Bed management/IC/ES
Histopathological testing / Send sample from surgical or endoscopic procedure for identification of pseudomembraneous colitis.
· Send report to IC as well for CDI surveillance
Prevent transmission
Patient Placement / Private room for patients suspect or confirmed with CDI. If private room not available, in decreasing preference:
· Cohort CDI confirmed patient with patient with confirmed CDI, and no other infectious communicable disease
· Cohort with patient suspect with CDI, and no other communicable infectious disease
· Cohort with non CDI patient, with no other communicable infectious disease.
· If shared bathroom use bedside commode for elimination.
Hand hygiene / 1. Establish hand hygiene protocol for patients with CDI. Options:
· For every encounter with the CDI patient environment or patient care activity, after removing gloves, and when hands are soiled wash with soap and water.
· Cleanse with alcohol hand rub unless outbreak or increased incidence of CDI on unit or in area; utilize handwashing for all soiled hands
2. Encourage visitors to practice appropriate hand hygiene when leaving the patient room
3. Provide hand hygiene opportunities for bed-bound patients, those who use commodes, and those who leave the contact precautions room for diagnostic tests, rehab, etc.
Contact Precautions / What
1. Gloves to enter the room, gowns if attire may become soiled or for contact with patient, environment or care equipment OR:
Gowns and gloves to enter the room
2. Encourage visitors to observe contact precautions if assisting in patient care responsibilities or potential for soiling of hands or clothing.
When
1. Contact precautions for all patients confirmed or suspected with CDI:
· for the duration of signs and symptoms OR:
for the duration of admission
· Contact precautions for patients who have CDI related colectomy surgery until rectal stump drainage ends
2. Contact precautions after laboratory testing is negative for toxin in symptomatic patients identified at risk for recurrent CDI.
PREVENT TRANSMISSION (cont)
Cleaning and Disinfection of Equipment and Environment / Equipment
1. Use dedicated disposable or reusable equipment until patient discharge with appropriate cleaning and disinfection prior to reuse OR:
Use dedicated equipment until no further symptoms of CDI for 48 hours. Clean and disinfect reusable equipment prior to use for another patient OR:
If dedicated equipment is not possible or feasible, clean and disinfect equipment prior to use for another patient
2. Ensure that reusable equipment is appropriately cleaned and disinfected prior to use on any other patient
3. Ensure that commodes, if used, are not shared between patients until appropriately cleaned and disinfected
Environment
4. Enhance efforts to ensure that surfaces and equipment, restrooms and commodes are cleaned and disinfected at least daily and when soiled.
5. Ensure commonly touched surfaces are cleaned and disinfected at least daily and episodically throughout the day, including light switches, door knobs, monitors, over-bed tables, side rails, sinks and toilets.
6. Launder cubicle and window curtains upon discontinuing contact precautions.
Cleaning solution options
· Routine cleaning with EPA approved hospital grade cleaner/ disinfectant unless outbreak or increased incidence or suspicion of transmission
· Use of an EPA registered disinfectant with EPA label for C. difficile spores for room cleaning and all commonly touched surfaces, and restroom/ commode cleaning during outbreak or increased incidence OR:
· Chlorine based cleaner/ disinfectant for room cleaning and all commonly touched surfaces, and restroom/ commode cleaning during outbreak or increased incidence
New technologies:
· Hydrogen Peroxide mist room disinfection
· Ultraviolet light irradiation disinfection of environment and contents
Communications and Education
· Develop process so that ES staff know that rooms need daily and terminal cleaning in accordance with CDI prevention guidelines.
· Flag medical record for history of CDI
· On transfer or discharge, communicate CDI diagnosis to receiving facility or agency
· Educate patients, families and vistorys
Prevent recurrence
Antimicrobial stewardship / 1. Implement or enhance an antimicrobial stewardship program.
2. Minimize the frequency and duration of antimicrobial therapy
3. Minimize the number of antimicrobial agents prescribed. Restrict some antimicrobials to the direction of oversight group (P&T, etc.)
Communication on transfer / 1. Provide education on CDI to patient and family
2. Reinforce the importance of hand hygiene, personal protective equipment, and appropriate cleaning and disinfection
3. Communicate infection status with receiving facility
1. APIC Guide to the Elimination of Clostridium difficile in Healthcare settings 2008
2. SHEA-IDSA Cohen, S. H. et al, Guideline Infection Control land Hospital Epidemiology May 2010 Vol 31, No. 5
Prepared for the Massachusetts CDI Prevention Partnership Collaborative Workshop November 15, 2011